Physician Burnout Will Burn All of Us

Executive Summary

It’s hard to find anyone these days who is happy with the health care system. But for physicians, it’s much deeper than unhappiness—it is about burnout.

Physician burnout has been on the rise, increasing 17 percentage points in the decade between 2011 and 2021. This isn’t just an isolated issue for physicians. Physician burnout is costly for all of us. It impacts patient care and patient safety, as research shows that physicians suffering from burnout are more than twice as likely to be involved with patient safety incidents than physicians who are not suffering from burnout. Burnout also increases health care spending, as physician turnover related to burnout costs the health care system an excess of $260 million a year. And burnout is especially an issue for worsening health care access and outcomes in underserved rural communities and communities of color, where much-needed physicians are leaving their practices. Nearly one-half of physicians exiting the workforce cite burnout as a major reason. Not every physician is experiencing burnout equally—female physicians are experiencing a burnout rate of 63 percent in contrast with their male counterparts at 46 percent—and this has special implications for certain specialties dominated by female doctors, such as primary care and obstetrics, which are, not uncoincidentally, specialties with high burnout rates as well.

Physician burnout can’t be explained by any one particular cause but rather by a multitude of pain points that are also making things worse for patients. The financial incentives, corporatization, and increasing vertical and horizontal consolidation in health care are squeezing physicians and making it harder for them to prioritize patient care, earn patient trust, and build relationships. A majority of hospitals today are owned by large national chains compared to just 12 percent of hospitals in the 1980s, and roughly 70 percent of physicians work for these corporate entities.

Physician burnout can’t be explained by any one particular cause but rather by a multitude of pain points that are also making things worse for patients.

Politicization of the health care system—in part driven by extremist movements interfering in care—also hasn’t helped. The fight over abortion rights, gender-affirming care, and COVID-19 care and vaccines has only increased stress on many physicians and interfered with physician’s ability to provide medically necessary care—factors that contribute to burnout. Currently, twenty-one states have banned abortion or restricted the procedure earlier in pregnancy than the standard set by Roe v. Wade, and twenty-one states have banned gender-affirming care for youth.

Physicians of color, women physicians, and physicians with disabilities may be even more vulnerable to burnout, as they already face multiple barriers in the health care system—from access to the profession in the first place, to advancement and recognition once in practice. Only four of the 193 accredited medical schools in this country are located at Historically Black Colleges and Universities (HBCUs), training half of the country’s Black doctors.¹ Female physicians earn just 74 cents for every dollar earned by male physicians, creating major pay inequities, and they also experience inequitable treatment in the workforce. Physicians with disabilities are almost hidden, making up only 3.1 percent of the physician workforce with little research on their experiences and also inflexible accommodations of their needs. Yet at the same time, we know that care provided by a diverse physician workforce is critical to improving health outcomes for a diverse population and also to health equity.

Lastly, the cultural and physical environment of the health care system itself can be physically and emotionally unsafe for physicians and other members of the health care workforce, in part related to many of the other factors named above. Physician rates of death by suicide are double that of the general population, with little progress on changing the environment in a meaningful way to accommodate and support their needs.

There are things that policymakers can do to address the pain points contributing to physician burnout. Banning anti-competitive terms in physician employment contracts, such as noncompete agreements; expanding visibility into financial incentives underpinning the health care system, such as by requiring additional reporting and increased regulatory review of horizontal and vertical mergers; and strengthening worker protections in the health care setting, including physician rights to unionize, will go a long way.

Introduction

The health care sector in the United States has suffered from a shortage of physicians for many years. It simply doesn’t have enough of them to meet the country’s health care needs, especially in certain areas. Across the country, there is a predicted shortage of 57,259 physicians in 2025 and that is expected to climb to 81,120 in 2035, when the population is also expected to be disproportionately older and need more health care services.² Shortages are expected to be the worst in rural areas—which will face a shortage of nearly 52 percent of physicians needed by 2035—and also in certain specialties, such as general internal medicine, geriatrics, and obstetrics–gynecology (OB–GYN).³ There is also a significant shortfall of physicians of color. For example, Black physicians make up only 5 percent of the workforce and 14 percent of the population. All of these issues have major implications for patient care, access, and health equity.

Rather than making headway in developing and retaining the physicians it needs, the United States is losing ground. Physicians are leaving the profession at remarkable rates. One of the central reasons they are doing so is burnout—nearly half of physicians exiting their practice cite burnout as a major factor.⁴ And one particularly troubling fact is that the physicians reporting highest rates of burnout are often the ones that are needed the most in terms of providing equitable care that patients need, including the youngest doctors, female physicians, physicians in emergency medicine, internal medicine, and obstetrics–gynecology.

While physician exit due to burnout was exacerbated by the pandemic, this was only the acceleration of an existing trend. Rates of burnout reported among physicians have been steadily increasing over the last ten-plus years, from about 39 percent of physicians in 2011 to 58 percent in 2021.

While physician exit due to burnout was exacerbated by the pandemic, this was only the acceleration of an existing trend.

Physician burnout is costly. It robs the U.S. health care system of efficiency, results in poorer health outcomes and patient safety issues for everyone, and in particular contributes to large, increasing, and avoidable inequities in health care for populations that have been most marginalized and who already face barriers to care, such as individuals with lower incomes, people with disabilities, the uninsured, communities of color, and those living in rural areas.⁵

Physician burnout is only one problem plaguing America’s health care system and standing in the way of advancing access to equitable, affordable care. There is much work to be done, for example, to address factors such as structural racism and other forms of discrimination, inequitable obstacles to becoming a physician, perverse incentives in health care payment, health care corporatization and consolidation, the transactional culture that impedes person-centered care and the incredible complexity of the health care infrastructure, to name just a few. But physician burnout is important to address because it is surging, because it has a significant impact on patients, and because reducing it could do much to help reverse the damaging trend of physician exit, while also improving outcomes for all, especially patients who are most at risk.

This report will explore physician burnout, including who is leaving the profession, the impacts on the health care system and health equity, and the factors and pain points that contribute to physician burnout and exit. It will then present a framework of principles and policy recommendations that can be used by policymakers and others that want to help drive change, reverse the trend of physician burnout and exit, and improve the overall system.

How is physician burnout manifesting and who is it harming?

For the past several years there has been increasing attention paid to the problem of burnout—particularly due to moral injury—among physicians in the United States, a trend that has gotten worse over time.⁶ Burnout is defined as chronic workplace stress that is not effectively managed.⁷ Moral injury is a particularly important subset of the stressors that contribute to burnout and is caused by being part of a system that conflicts with one’s moral beliefs.

The COVID-19 pandemic did not cause physician burnout, but it did place an additional strain on already strained physicians and also drew increased attention to the problem. In 2011, 45.5 percent of physicians reported feeling burned out. By 2021, this percentage had increased dramatically, to 62.8 percent–a 17 percentage point jump.⁸

Figure 1

Impact on physicians and the health care system

The problem of physician burnout is not the same across specialties, gender, or age. According to a recent Medscape survey, the highest rates of burnout were concentrated in emergency medicine, internal medicine, and obstetrics–gynecology. A separate study showed that in April 2021, 71 percent of primary care physicians said their level of burnout was at its highest levels ever, and by the fall of 2021, 44 percent of primary care practices reported facing clinical turnover in that year.⁹ Not unexpectedly, some of the specialties with the highest rates of burnout also had some of the highest rates of exit from the workforce.¹⁰ Of course, much of this had to do with the pandemic but, as mentioned earlier, the pandemic only accelerated trends that already existed.

Female physicians report significantly higher rates of burnout than male physicians (63 percent versus 46 percent), due to a multitude of factors, including greater challenges related to some of the pain points (described later in the report), such as inequity in pay and advancement opportunities.¹¹ Female physicians also appear to exit the physician workforce at higher rates than male physicians; there is limited academic research on this trend, but one study focusing on female physicians in academic medical centers found that female physicians leave these settings at higher rates than men, as did a similar study of female physicians in emergency rooms as compared to male emergency room doctors.¹² Physicians in the oldest age group (over 65) are less likely to suffer from burnout than the youngest physicians, those under 35 years of age.¹³ While there are likely many reasons behind this age-related difference in burnout, some research points to longer work hours and additional strains from family caregiving responsibilities at home for younger physicians.¹⁴

Figure 2

Figure 3

Impact on patients

Physician burnout is a problem not only because of concern for the well-being of physicians, but also because it matters to patient care and outcomes. For example, research shows that physicians suffering from burnout are more than twice as likely to be involved with patient safety incidents than physicians who are not suffering from burnout.¹⁵ Because burnout is highly associated with physicians leaving the patient care workforce prematurely, this also presents a major care access issue. According to an analysis conducted in 2022, the attributable risk of turnover due to burnout during a two-year span among primary care physicians (PCPs) is approximately 4 percent.¹⁶ One study looking at association between loss of a primary care physician on patient care for Medicare beneficiaries found that it was associated with 18.4 percent fewer primary care visits, 17.8 percent more urgent care visits, 3.1 percent more emergency department visits, and 6.2 percent more specialty care visits.¹⁷ Potentially, as primary care shortages get worse over time, in part because of burnout, this could have the effect of turning patients away from primary care at all, toward more expensive and potentially inappropriate specialty care, because of access challenges. Where there are more primary care physicians per capita, there is also a positive impact on life expectancy. One study found that a total of ten additional primary care physicians per 100,000 population corresponded to a 19.2 day increase in life expectancy.¹⁸ Thus, there is a potential that this loss of physicians due to burnout could negatively impact life expectancy significantly.

A separate study suggested that physician turnover related to burnout costs the health care system an excess of $260 million a year, in part because of increased use of specialty, urgent, and emergency care.¹⁹ This may also be understating the cost of burnout, as the study only accounted for cost related to turnover and not cost related to patient safety, quality of care issues, malpractice claims, or other less quantifiable factors relating to the physicians’ mental and physical health. It also uses physician burnout rates from 2017–18, which were much lower than today’s rates.

Physician turnover related to burnout costs the health care system an excess of $260 million a year, in part because of increased use of specialty, urgent, and emergency care.

Physician shortages, exacerbated by burnout, not only have an impact at the population level, but, for people of color, the uninsured, those with low incomes, and people with disabilities, these access issues are made even worse because of structural discrimination built into the system. For example, workforce shortages make it much harder for people to access culturally and linguistically appropriate care or to find a provider who accepts Medicaid coverage, which is the predominant insurer for low-income people and people of color.²⁰ In many places, long wait times for primary care and specialty appointments are already a major problem, and these wait times have a greater impact on people who have less flexibility in their work schedules, with caregiving responsibilities or transportation needs.²¹

What are the pain points causing problems for physicians?

The health care system is complex, so of course the answer to every question about the system is multifaceted. However, there are several pain points in the system helping to explain, at least in part, why stress and burnout has become so problematic for physicians and especially particular sub-groups of the physician workforce. These pain points can be grouped into three categories: for-profit motives in health care, the increasing politicization of health care decision making, and discrimination in the health care system.

For-profit motives are harming the health care system

The financial pressures on physicians are tremendous and getting worse, in part because of the corporatization and consolidation of the health care system. In the 1980s, only 12 percent of hospitals were owned by large national hospital chains. Today, the majority of hospitals are owned by just a few major companies, including investor-owned companies such as HCA and Tenet, as well as nonprofit systems, which increasingly are adopting some of the same practices used by for-profit companies.²² These horizontal consolidations have meant some economies of scale, but also multiple closures, especially in rural areas, and investors and administrators are often more concerned about revenue than patient outcomes and health access.

There has also been extensive vertical consolidation, with hospitals acquiring many physician practices. For example, from 2012 to 2018, hospital ownership of physician practices increased 128 percent²³ so that now 70 percent of physicians work for hospitals or corporate entities.²⁴ As a result, many physicians who used to make their own decisions regarding patient care now must increasingly focus instead on delivering revenue to their employers.

Financial incentives lead to a transactional rather than a relational focus

Typically, physicians are not paid for their time but instead paid based on their production: the more volume of work a physician performs, the more money they bring in and the more they are paid.²⁵ This production is measured in Relative Value Units or RVUs.²⁶ The impact that these financial incentives have on overuse of health care services and on health care costs overall is well documented. What is less appreciated is how these incentives contribute to conditions that lead to physician burnout.

Even for nonprofit hospitals, the incentive for physicians is to meet productivity metrics and bring in more revenue rather than metrics that are more relational and outcomes-based. It is worth noting that even though there has been a trend in medicine toward paying for value over volume, especially for Medicare, this type of payment does not usually impact the individual physician, who is still compensated and rewarded based on volume.²⁷ What this means in practice, for example, is that a primary care physician is paid more if he/she sees five patients in an hour than if he/she sees one patient in an hour. This constrains the time that physicians feel that they have to get to know the patient and understand the complexity of the patient’s situation. Physicians can make the decision to schedule fewer patients and spend more time with their patients, but this will impact their compensation. This is one of many reasons why female physicians earn less than male physicians; they tend to spend more time with an individual patient, allowing for fewer patients overall thus lower volume and lower revenue.²⁸ The transactional nature of physician–patient interactions contributes to burnout because it can make physicians feel like they don’t have the time and space to better understand the context for the patient’s symptoms to provide the diagnosis, and are more mechanistic in their interactions. As one physician who left her practice noted, “It felt like the bean counters were in charge, and it wasn’t about patient care any longer…I didn’t feel like we got recognized for what we did. It wasn’t like I wanted an award, but more like recognizing [that] not every patient fits into a 15-minute slot, and doctors aren’t just widgets in a factory.”²⁹

Even for nonprofit hospitals, the incentive for physicians is to meet productivity metrics and bring in more revenue rather than metrics that are more relational and outcomes-based.

Of course, reversing this trend toward transactional relationships in health care provision would do more than just reduce physician burnout—it would improve patient outcomes, as well. A study from the Annals of Family Medicine has found that when the quality of patient–provider relationships improve, so do patient health outcomes, making having a trusted relationship with one’s physician a critical element of primary care.³⁰

Corporatization of health care leads to increased stress

The shifts resulting from corporatization and consolidation have had an impact on providers, with increased pressure to produce and meet financial targets, as well as a recognition that corporate leaders may decide to replace physicians with other members of the workforce to save costs.³¹ With a constant focus on the profit margin and volume-based incentives, the drive to minimize labor costs means reduced physician staff and also reduced staff to help support physician needs. This has induced major stress on the physician workforce, especially in the emergency department, where private equity influence on the care delivery model has increased dramatically.³² But in general it has meant a pressure on physicians to increase revenue, which means identifying ways to expand reimbursement—more services, more treatment codes to associate with patient care. This is not necessarily better for the patient, but does mean higher costs and moral injury for the provider, who is being asked to prioritize highest-billing reimbursements regardless of patient care and need. Multiple studies have found that this shift in physician practice integration and increased ownership by private equity has resulted in lower quality of care, poorer patient experience, and increased cost of care.³³ Corporatization and consolidation also disincentivize relationship building—not just with patients but also with colleagues—which is another source of stress.

With a constant focus on the profit margin and volume-based incentives, the drive to minimize labor costs means reduced physician staff and also reduced staff to help support physician needs.

This focus on production also leads to a feeling for physicians of being undervalued. This is especially true for specialties that are reimbursed at lower rates and therefore physicians in these specialties feel their importance diminished as contributors to the broader system. This not only contributes to burnout but also the likelihood that patients seeking care in areas with lower reimbursement rates suffer as a result. For example, one female physician who works on family planning and abortion care noted, “Your value to a health care system has to do with how much money you make, the RVUs [relative value units] you bring in. That [family planning] care tends to be less valued by health care systems than orthopedics or cardiology. That ends up permeating across the quality of care that patients receive because there is less money to support the care that is being provided.”

Administrative burden related to insurance and electronic health records

Prior to the Affordable Care Act (ACA), insurers could seek to control costs with pre-existing condition exclusions, or charging different rates for patients depending on expected costs. Now, as the insurance market has changed but health care costs have continued to skyrocket, one way that insurers appear to have responded (though lack of transparent data on this makes it hard to know) is with increased utilization review.³⁴ These reviews, including prior authorization approvals required by insurers, mean that physicians are spending significant time trying to justify their care and treatment decisions and getting insurers to agree to pay for treatments and services that they believe patients need. This detracts from physician time with patients and may lead to worse health outcomes.³⁵ Each insurer has a different set of utilization rules, negotiated prices, benefit design, and other hurdles that patients and providers need to deal with in order to provide and get reimbursed for care. An overwhelming 85 percent of 1,501 physicians surveyed by the Physicians Foundation found that administrative burden, including prior approvals, are a challenge to providing high-quality patient care.³⁶

Time spent on electronic health records (EHR) is also a major stressor for physicians. Many physicians report that EHR systems can be challenging to use, sometimes leading to patient harm, and also that payers require significant documentation.³⁷ Estimates of physician time spent on the EHR varies, but one study found that primary care physicians spend about sixteen minutes per patient visit on an EHR.³⁸ Given the focus on volume in the health care system, it is easy to imagine why this time on EHRs would be a major source of stress for physicians. In one physician survey, 75 percent of respondents attributed burnout to EHRs.³⁹ Again, this focus on time on the electronic health records further detracts from time with patients and colleagues.

Lack of physician agency and autonomy

Another predominant trend in health care related to the increase in consolidation is diminished agency and autonomy for physicians. One way that this has manifested is with an increase in requiremen ts on physicians to sign noncompete agreements (noncompetes).⁴⁰ Noncompetes are contractual agreements between an employer and worker that bind one in five American workers.⁴¹ They block the worker from working for a competing employer or starting their own competing business within a specific geographic area or period of time after their employment ends, consequently preventing workers from leaving jobs, decreasing competition for workers, and lowering wages. They are not popular among physicians.⁴² A 2022 survey of 558 doctors across specialties found that more than 90 percent of respondents either currently or previously had been bound by a noncompete agreement.⁴³ Due to these contractual agreements, the physicians were forced to either stop working, commute very long distances, move to a new area, or switch fields. In a consolidated market, a physician needing to find a job outside the geographic area served by the network they are leaving can be highly disruptive for physicians and their families. These agreements also disincentivize relationship-building and trust with patients since, if providers do move to a different practice or location, under these agreements they are not allowed to tell their patients about their new location. If these agreements force physicians to relocate into a completely different geographic area in order to legally work, that can sever long-term patient-provider relationships, which has implications for patient outcomes as continuity of care has been associated with increased use of preventive services, and lower rates of hospitalization.⁴⁴

Key Takeaway

The bottom line is that the health care system is increasingly consolidated and corporatized, a process that has contributed to an increase in health care costs without a commensurate increase in quality or improvements in health equity. It has also resulted in diminished agency and autonomy for physicians and increased administrative burden and oversight by insurers seeking to minimize costs. All of this is resulting in physician stress, burnout, moral injury, and less time to form trusted relationships with patients and to prioritize patient care, which only serves to compound the poor effects on health outcomes and costs of a consolidated system. There are several features of the current federal policy environment that have encouraged these trends, including lack of transparency into health care costs and prices in the commercial market, lack of federal oversight over anti-competitive practices in health care, and a lack of accountability for health and health equity. Another challenge is that these systems are politically powerful and influential. Patient and consumer advocacy groups and community and physician groups that might oppose these system interests have not organized and consolidated their power in the same way.

The bottom line is that the health care system is increasingly consolidated and corporatized, a process that has contributed to an increase in health care costs without a commensurate increase in quality or improvements in health equity.

Politicization of health care decision making is preventing physicians from focusing on patient care and relationships

Another clear threat to many physicians’ ability to form trusted relationships with patients and opportunity to provide patients with the care that they need is the increasing politicization and interference of targeted extremist movements in many components of health care, especially in the areas of abortion care, gender-affirming care, and the COVID-19 pandemic. This politicization is harmful to patients and providers alike.

Abortion care

Since the Supreme Court’s decision in Dobbs v. Jackson Women’s Health Organization in 2022 that upended the federal right to abortion in the United States, health care workers who provide abortion care or even counsel patients on abortion as one of their health care options have been forced to choose between their moral and professional obligation to their patients and the potential legal repercussions that may be in place depending on which state they live in. In large portions of the country, abortion bans and restrictions have been enacted, resulting in a lack of meaningful abortion access.⁴⁵ For other states where the legal situation remains uncertain, a complex environment exists that has created challenges for both patients and clinicians to navigate.⁴⁶ In a recent survey, a majority of OB–GYNs said that the Dobbs ruling has worsened their ability to manage pregnancy-related emergencies and worsened the ability to attract new OB–GYNs to the field.⁴⁷ What’s more, this same survey found that over four in ten OB–GYNs are very or somewhat concerned about their own legal risk when making decisions about patient care and the necessity of abortion.

The fallout of the Dobbs decision has also created a dearth of comprehensive training for abortion care in states with abortion restrictions, preventing new doctors from being able to learn how to provide abortion care. Right now, 45 percent of the 286 accredited OB–GYN programs in the country are operating under abortion bans.⁴⁸ Medical school faculty worry that this new legal landscape will drive new doctors away from states with abortion bans, reducing the number of physicians available not only to provide abortions, but also to conduct genetic screenings, care for miscarriages, deliver babies, and handle unpredictable pregnancy risks for millions of patients.⁴⁹ In 2017, ACOG released a study showing that half of all counties in the United States lack an OB–GYN, which is already problematic and doesn’t leave space to get much worse. Considering the already dismal and worsening maternal mortality crisis in the United States, this is a pressing issue.⁵⁰ A recent March of Dimes report suggests that in areas where there is very little or no access to maternity care, also known as maternity care deserts, approximately 6.9 million women and almost 500,000 births are impacted by poorer access to prenatal care and worse maternal health outcomes.⁵¹

Right now, 45 percent of the 286 accredited OB–GYN programs in the country are operating under abortion bans.

Some of these worrying trends will also impact future workforce recruitment and training. The Dobbs decision has become a discouraging factor for medical students to choose obstetrics–gynecology as a field, further hurting predicted shortage rates in this specialty area.⁵²

Gender-affirming care

Another highly politicized issue challenging providers and patient care is the dramatic recent increase in gender-affirming care bans.⁵³ Already, 2023 has been a record-setting year for attacks on transgender rights through anti-trans legislation, with a particular escalation in the health care space related to gender-affirming care bans.⁵⁴ As of July 25, 2023, twenty-one states have banned gender-affirming care for youth and seven states are considering these types of bans.⁵⁵ This means that providers in these states are unable to provide the type of care that they consider medically necessary for their patients. It also means that providers in states where gender-affirming care is still legal face additional significant burden to meet patient needs.⁵⁶ What’s more, the media is reporting some spillover effects of major fear for providers, such as pediatricians and mental health care practitioners, who provide health care outside of gender-affirming care to transgender patients, and also fear getting in legal trouble.⁵⁷

The COVID-19 pandemic

The politicization of COVID-19 health-protective behaviors in the United States has resulted in an altered perception of the risk of infection and put millions of Americans in harm’s way, especially health care workers and the immunocompromised.⁵⁸ The reasons behind the politicization of the pandemic are numerous, but some of the main causes include the propagation of misinformation and disinformation and a growing anti-vaccination movement. This politicization has challenged the ability of physicians to form trusted relationships with patients, which are critical for promoting patient adherence to physician recommendations and prescriptions, including for preventive health care such as vaccines.

The COVID-19 pandemic is the first of its kind to take place in the environment of unregulated Internet information, social media, and round-the-clock polarized news coverage. Especially in the first several months of the pandemic, the U.S. public was bombarded with different information from sources of varying reliability. Like the virus itself, misinformation has spread rapidly, largely due to social media. Researchers have developed methods to better understand the spread of misinformation, coming to the conclusion that those who identified along political extremes were most likely to believe misinformation that confirmed their pre-existing biases.⁵⁹

Directly related to the misinformation crisis is the anti-vaccine crisis. While the anti-vaccination movement in the United States existed long before the COVID-19 pandemic began, the movement has grown and morphed in dangerous new ways since the start of 2020, despite vaccination being considered the most effective protection against COVID-19 and the best way to prevent further COVID-19 caused deaths. It is essential to note that in the United States, some racial and ethnic minorities have vaccine hesitancy and are distrustful of the health care system for historically painful reasons. In the Black community specifically, many are cautious about seeking medical and preventive health services due to incidents such as the unethical Tuskegee Experiment. These concerns are not only valid, but must be approached with cultural sensitivity and acknowledgment of harms.

No matter the reason behind why a patient may be vaccine-hesitant or believe COVID-19 misinformation, it is the responsibility of their health care providers to build trusted relationships with them and be able to take the time to help them understand the science and work together to establish the best care plan. Research has found that there is a strong positive relationship between trust and COVID-19 vaccine uptake, meaning that without patients having trust in their physicians, it is less likely that they will get vaccinated if they were already vaccine-hesitant upon arriving at the hospital or clinic. Misinformation campaigns and the anti-vaccination movement have made it so that physicians have to work even harder to compassionately educate and build a rapport with their patients. If a patient has already spent hours reading or listening to scientifically inaccurate information about COVID-19 from sources in the news or social media that they trust, ten to fifteen minutes spent with a physician they don’t have a strong trusting relationship with will be unlikely to make a difference. With the changing financial incentives and pressures on the physician that detract from time and relationship with the patient described above, having the time to build this type of trust can be another real challenge faced by physicians.

Misinformation campaigns and the anti-vaccination movement have made it so that physicians have to work even harder to compassionately educate and build a rapport with their patients.

It is important to acknowledge that physicians are not immune to the politicization of the COVID-19 pandemic or anti-vaccine momentum. While an AMA survey found that 96 percent of physicians were fully vaccinated against COVID-19 in 2021, some physicians have promoted vaccine skepticism.⁶⁰

Key Takeaway

The bottom line is that for many physicians across the country, being able to put patients’ needs first has become increasingly challenging due to increased fear and legal and judicial oversight that has threatened bodily autonomy for patients and threatened physicians’ ability to provide medically necessary care in a safe and trusted environment. Also, the politicization of the COVID-19 pandemic has challenged trust that patients feel in the public health and health care system and in their providers recommendations, which has an impact not only on public health but also on the physician–patient relationship.

Racism, sexism, and ableism in the health care system

Structural inequity in the health care system is another major issue for physician and patient well-being. There has been increased attention to the disparities that characterize our health care system, especially since the start of COVID-19.⁶¹

While women physicians report higher rates of burnout than men, the burnout rate for physicians of color is not higher, and there are no data for disabled physicians at all with regard to this issue. However, there is no denying the barriers and other stressors they encounter on a daily basis during their medical training and as practitioners, on top of all of the other pain points discussed in this report. Additionally, there are compounding intersectionalities across these groups. (It is important to acknowledge here that this report does not discuss the many challenges faced by physicians from other marginalized populations, such as doctors who are immigrants, or doctors who identify as LGBTQ.)

Expanding diversity, equity, inclusion, access, and belonging for physicians with all types of lived experiences will help to expand equitable care. Meeting this challenge begins with expanding access to opportunities in education, training, support, and advancement as well as removing racism, sexism, and ableism from the field of practice.

Racial equity

While burnout rates do not appear to be higher for physicians of color, one of the major challenges in medical care is the real lack of racial and ethnic diversity among physicians.

Figure 4

About 5 percent of the physician workforce is Black, and this has stayed relatively constant for decades.⁶² There is variation by state, but in almost all states, the percentage of Black physicians in the workforce is lower—often much lower—than the percentage of Black people in the population.

One of the reasons there is a dearth of Black physicians is that the fields of medicine and medical education in the United States were intentionally built upon the national legacy of segregation, setting up Black medical students and physicians to be excluded from premedical education, medical education, and professional work.⁶³ For example, the American Medical Association, a leading professional association and lobbying group of U.S. physicians and medical students, has a racist history, including the exclusion of African American physicians and racially integrated delegations starting from the group’s beginnings in the late 1800s and persisting well into the 1900s.⁶⁴ In the present day, Black, Indigenous, and other people of color still face structural barriers to entering the medical field for several reasons.⁶⁵ People of color are less likely to have accumulated wealth due to intentional policymaking, as seen in the Black–white wealth gap, making it harder to access and afford higher education opportunities, a necessary step to medical education.⁶⁶ While some efforts have been made to recruit a more diverse student body in the medical profession, such as through loan repayment programs and accreditation requirements, the lack of racially concordant mentors and limited exposure to health careers for students living in many communities of color continues the cycle of discouraging diversity in the health care workforce.⁶⁷ The Association of American Medical Colleges has committed to expanding diversity in medical education and reported that 10 percent of incoming medical students in the 2022–23 incoming class were Black and 12 percent were of Hispanic, Latino, or of Spanish origin, representing slight increases for both populations over the previous year.⁶⁸ However, the recent U.S. Supreme Court decision prohibiting affirmative action in higher education will make recruitment of a diverse health care workforce much more challenging.⁶⁹ Only four of the 193 accredited medical schools in this country are located at Historically Black Colleges and Universities (HBCUs). These four schools produce half of the country’s Black doctors.⁷⁰

Racism built into how the health care system actually operates in practice is also a major challenge for people of color seeking to become doctors. Even those who do make it through higher education and become physicians may face racism, discrimination, and bias from their patients and their peers in their resident training programs and once they enter the workforce.⁷¹ A recent New England Journal of Medicine perspective reports significantly higher “policing” of Black resident doctors’ behavior than that of white ones. While only 5 percent of residents in 2016 were Black, Black residents encompassed 20 percent of residents who were dismissed from their programs. This “biased scrutiny” of Black students continues a pattern that sadly often begins in early education.⁷²

Doctors and nurses of color also often report feeling tokenized, such as by being included in pictures and marketing materials disproportionately to how they are actually represented on the staff.⁷³ Also, certain accomplishments that are more accessible to white doctors than Black doctors are prioritized, such as academic awards or National Institutes of Health (NIH) research funding, and issues that Black doctors tend to focus more on, such as health disparities and community-based work or research, are undervalued in terms of reward and reimbursement. Doctors of color also report a higher emotional burden, reporting feeling the weight of responsibility to serve their communities, which means confronting racism in how insurance is structured, who is able to afford the care that they need, and social and structural determinants of health.⁷⁴

Diversifying the physician workforce would not only create new career pathways, mentorship, and higher-paying job opportunities for people of color, it also would benefit patients who are from the same or similar backgrounds and communities as their providers. Given the existing racial inequities in health outcomes in the United States, having health care workers that can understand, respect, build trust, and communicate with patients in need is critical. The major inequities in patient outcomes that currently exist can be mitigated by racially concordant care.⁷⁵ However, this is only possible if there is diversity within the health care workforce.

Gender equity

Another major structural discrimination issue in the health care workforce is sexism. The well-documented differences in pay between male and female physicians represent a significantly wider gender pay gap than in most other U.S. professions. Some researchers point to differences in negotiation when a physician is hired, or female physicians’ decisions to leave the workforce to have children as being the cause, but even that does not explain the outsized gender pay gap. One less-noted cause, as mentioned above, may be in how female physicians make choices to prioritize building trusted relationships with patients, which disadvantages them in terms of pay. One study in the New England Journal of Medicine found that female physicians generate less revenue than male physicians, but spend more time with their patients.⁷⁶ Another study found that there is real gender discrimination in pay, rewards, honors, referral patterns, promotion opportunities all of which compounds making female physicians more likely to change jobs.⁷⁷ Also, some of the medical procedures that focus on female patients, performed by specialties more common among women physicians, such as obstetrics–gynecology, actually pay less than similar procedures performed on men.⁷⁸ The political issues facing abortion care, as described above, are also more likely to burden female physicians as they are, again, more likely to be in the obstetrics–gynecology field.

One study in the New England Journal of Medicine found that female physicians generate less revenue than male physicians, but spend more time with their patients.

Much of the data on burnout and stress in the field of medicine shows significant differences between female and male physicians.⁷⁹ Research suggests that patient outcomes can be better under the care of a female physician rather than a male physician because female physicians are more likely to follow clinical guidelines, provide preventive care more often, and engage in better communication with patients, including focusing on trusted relationships.⁸⁰

Disability equity

A discriminatory issue that gets even less attention in the physician workforce is ableism. Physicians with disabilities represent approximately 3.1 percent of the physician workforce in the United States as compared to about 25 percent of the overall population.⁸¹ Further research is needed to better understand how structural factors discourage people with disabilities from entering the medical field, but AMA ethics discussion of the issue suggests some of the following challenges: narrow interpretations of motor, sensory, and cognitive requirements for admission to medical school that discriminates against people with disabilities in a variety of ways, and denial of accommodations in medical schools and training programs, potentially due to lack of familiarity with what schools need to do to become more accommodating.⁸² However, research suggests that one of the limiting factors is also fear of stigma in asking for accommodations and lack of clarity on processes to ask about these accommodations.⁸³

Physicians with disabilities represent approximately 3.1 percent of the physician workforce in the United States as compared to about 25 percent of the overall population.

Some accommodations that medical schools and health care training programs should pursue include offering American Sign Language interpretive services, schedule accommodations, standard dictation software, and a program of general education and familiarity with supportive practices that can remove the exhausting mental and physical burden on people with disabilities to self-advocate.

More research is also needed on the benefits to patient outcomes of having providers with disabilities, as many disabled patients report that physicians “just don’t get disability”; presumably, providers who need accommodations are better situated to understand patient needs than providers who don’t have lived experiences with a disability. Of course, initiative in this direction must acknowledge that disabilities are not monolithic, and living with one disability does not demonstrate knowing what it is like to live with another.⁸⁴ As stated by a deaf physician:

The single most important insight I have gained from being a disabled doctor is that I really have no idea what life is like for my patients…. The disability I know best is deafness. The profession I know best is medicine. So I accept that I’ve no idea how life is for, say, an accountant with cerebral palsy. But I do at least know what not to do if I should meet such a person. I won’t automatically assume that they can’t do certain things—nor will I blithely reassure them that they can. I’ll steer away from the all-or-nothing questions (”Can you do X? Can you do Y? Can you do Z?”) and try to build up a picture of a more complex reality. Above all, I will let them tell me how it is.⁸⁵

Key Takeaway

The bottom line is that the structures of discrimination that have been built into the policies, practices, and norms in the United States are also part of how its health care system operates. They dictate who has fair and just opportunity to enter the medical profession, be supported, and thrive. Even though having a diverse physician workforce that represents the heterogeneity of the country would be better for advancing equity in patient outcomes, there are many structural barriers in education, pay, and accommodations that continue to perpetuate inequities by race, gender, disability, and other identities.

Threats to physical health, mental health, and safety

The COVID-19 pandemic drew significant attention to many of the inherent physical and mental health challenges that exist for the health care workforce, including doctors. And of course it is no coincidence that burnout rates among physicians have skyrocketed since the pandemic began, suggesting that perceptions of safety during this time is a major factor. After December 2020, when vaccines and protective personal equipment were more readily available, this particular COVID-19 specific threat diminished, on average, for many doctors, but in general, doctors still do face higher than average threats to their physical safety in the workplace. Some of these threats include injuries related to needle sticks, direct contacts with hazardous materials, musculoskeletal injuries, and violence, which has unfortunately also become increasingly common.⁸⁶ Specifically, since the Dobbs decision, there has been a notable increase in violence or threatened violence against abortion providers, including arson, burglaries, death threats, and health care setting invasions, as anti-abortion extremists become more emboldened.⁸⁷ There is a clear link between physician physical safety and patient care. Physicians who are in unsafe working environments are less able to provide quality care to their patients and, in the case of an infectious disease such as COVID-19, are putting their patients at risk if they are not properly protected.

Since the Dobbs decision, there has been a notable increase in violence or threatened violence against abortion providers, including arson, burglaries, death threats, and health care setting invasions, as anti-abortion extremists become more emboldened.

Mental illness

Rates of mental illness among physicians are high and have become even more elevated since the pandemic began (a trend also seen in the general population). One specific mental health challenge brought on by the pandemic was related to chaos and uncertainty, especially at the pandemic’s start when new data was being published daily, guidelines were ever-changing, and physicians were navigating conflicting information from multiple trusted sources as well as information and misinformation being introduced by patients and fringe groups. Also, just as in many other professions, much of the collegiality that can serve as a stress buffer was lost in the physician workplace as the pandemic raged on. Physicians, just like many others, became more secluded during the pandemic due to the rise of virtual telehealth practice and fear of infection keeping physicians from social gathering. Many of the pressures mentioned above also contribute to the feelings of isolation, such as changing employment model, and pressure to spend more time with the computer and electronic health records, rather than colleagues—which can be better for efficiency and payment, but worse for physicians’ mental wellness.

One particularly grim statistic is that physicians die by suicide at twice the rate of the general population. There are several reasons for this elevated rate, including ready access to lethal medications, high levels of personal and professional stress, gravity of life or death decision making (and related malpractice risk), and struggle with relationships in part because of work demands.⁸⁸ An estimated 10 percent to 15 percent of physicians will also develop a substance use disorder at some point in their careers.⁸⁹ Female physicians have higher rates of alcohol abuse than females in the general population, and addiction rates overall are especially prevalent among emergency room physicians, psychiatrists, and anesthesiologists.⁹⁰

Despite these high rates of mental illness, depression, suicidality, and substance use disorder, many, if not most affected physicians and medical trainees do not get professional help. This is likely due to a variety of factors, including stigma, lack of a primary care provider, challenges with accessing care due to inflexible work schedules, and, one factor that may surprise some people, affordability, especially if physicians want to go out of network to avoid facing colleagues and avoid insurance claims because of an interest in keeping these issues hidden.⁹¹ The physician culture makes it very hard for physicians to ask for help when needed. Many physicians are concerned about documentation of mental health issues haunting them or creating problems down the road for their medical licenses. Several state medical license applications and credentialing applications ask physicians whether they have a history of mental illness, including addiction and substance use disorder, and a physician may be concerned about repercussions if they seek treatment.⁹² This would be a major deterrent to seeking help.

Despite these high rates of mental illness, depression, suicidality, and substance use disorder, many, if not most affected physicians and medical trainees do not get professional help.

The financial model underlying the health care system (as discussed above) unfortunately makes it hard for physicians to take sick and family leave because they then won’t be able to meet their production targets and will suffer in terms of compensation—potentially even owing money to the employer based on the leave taken because of ongoing insurance costs during that time.⁹³ Again, this serves as a disincentive to physicians for taking time to take care of their needs.

Psychological safety

Many of these stresses faced by physicians also relate to a lack of psychological safety in the workplace. Psychological safety is the belief that you won’t be punished or mistreated for speaking up with ideas, questions, concerns, or mistakes.⁹⁴ Much of the research around fear of getting help for mental illness, substance use disorder, and, as described above, asking for accommodations related to disabilities and politicization of issues, such as abortion and gender-affirming care, also underscores the lack of psychological safety in the medical environment.

A 2022 advisory on physician burnout by the U.S. Surgeon General recommended that health care systems should provide mental health supports that are tailored for health care workers and also that systems should eliminate any discouraging punitive policies disincentivizing people from getting the mental health care they need.⁹⁵

One method of caregiving—called trauma informed-care—is part of an approach to changing the culture in health care systems so that physicians can address or at least be aware of the underlying trauma that relates to a patient’s need for care. Trauma-informed care acknowledges the importance of understanding the whole picture of what has happened with a patient, not simply the specific, acute issue at hand; of course, this acknowledgment of the role that pre-existing trauma plays in physical and mental health is no less important when the patient is a physician. Trauma-informed care can not only help patients but also the entire health care workforce, because the approach requires an organizational, comprehensive, and cultural awareness of trauma that helps to create a psychologically safer, more supportive environment free from stigma. In a psychologically safe environment, physicians and other members of the workforce will be more willing to ask for what they need to thrive—accommodations for disabilities, services to address mental health needs, and more.⁹⁶ The Substance Abuse and Mental Health Services Administration (SAMHSA) has provided a framework of how organizations can become more trauma informed.⁹⁷

Key Takeaway

Even though the health care system is intended to be a place of care and support, for many physicians, it is not a physically, mentally, or psychologically safe environment. Many of the reasons for this are related to what was discussed above, namely the consolidation, corporatization, and politicization of the health care system that make it hard for physicians to take the time to get the help they need or even introduce the potential for harm to physicians in health care settings. But there are also specific features of the medical environment and culture that contribute to a lack of physical and mental health supports and safety that could be changed in ways to promote greater well being for the workforce.

Principles for a healthy health care system

As described above, burnout among physicians and the pain points contributing to it are a major and growing problem in the United States. This has significant implications for health care and health equity, including care access, patient outcomes, and health care costs, not to mention the well-being of physicians. There has been some policy attention paid to workforce shortages since the start of the pandemic, but efforts to address these shortages without addressing these systemic challenges will not solve the fundamental, underlying problem. What follows is a framework of five guiding principles for policy changes that would not only help address physician burnout but would also promote access to affordable, equitable care for patients as well; after that, this report will present a list of possible federal, state, and nongovernmental policies that follow these principles.

1. Incentives in the health care system should reward outcomes and equity, not profits and power

Policymakers need to help break the cycle of consolidated power and profit-driven incentives that are contributing to physician burnout, high costs, and poor outcomes, and help shift financial incentives to prioritize trusted, dignified, respectful patient care. They can do this partly by requiring transparency and accountability from all health care organizations for improving health and health equity, and for being clear on financial arrangements that undergird health care organizations, to help expand understanding of health care system trends that are contributing to these broader concerns.

Incentivizing the health care system to reward outcomes and equity will also mean disrupting how resource flows are currently structured so that programs and populations most in need have the capacity to support patient care and workforce needs. In other words, this will require a shift in upfront investments to help support system changes needed to advance equity. This also requires a shift in how care is paid for, to allow a physician time and resources to care for patients and to recognize the value of equitable, supportive care. There has been a movement toward value-based purchasing in health care to shift incentives away from volume, but thus far the efforts have been imperfect, for several reasons—namely, that the measures used as the financial basis don’t necessarily center equity, that there is not a lot of transparency, and that, for physicians, even when they are part of these value based arrangements, they are often still paid based in volume-incentive structures.

2. Physicians should have a strong voice and power to push back against corporate interests

One of the major challenges with making significant policy changes to the health care system is that its power and resources are so concentrated. With the increasing consolidation and corporatization of health care, it is important that improving the system makes it easier for physicians to organize so that they can represent their collective interests, which requires that policymakers protect physician workers’ right to organize. Since the start of the COVID-19 pandemic, many health care workers have been active on the labor front to bargain for better working conditions.⁹⁸ Workers who have participated in many strikes include physician residents and interns.⁹⁹ Only 5.7 percent of physicians were in a union in 2014, and that number has increased slightly to approximately 8 percent of physicians belonging to a union today. This small-but-growing trend toward unionization is essential to helping physicians strengthen and elevate their voices and to join forces with consumer and patient groups also advocating for system change.¹⁰⁰ In some ways, the current environment makes it easier for physicians to unionize as they are more likely to be employees rather than in independent practices. However, in order to be able to unionize, they cannot be considered supervisors and some health care systems have used this to their advantage to stop unionization.¹⁰¹ The National Labor Relations Board has in some cases ruled in favor of physicians to protect their rights, but these protections could be strengthened.

3. Physicians should have the support to build trusted relationships with their patients

Physicians’ judgment and expertise increasingly are being undermined due to politicization and ideological extremism interfering in the health care system. We see this most recently and blatantly with abortion care and gender-affirming care bans and restrictions as well as in the politicization of information during the COVID-19 pandemic and its impact on trust in public health and health care. Patient/physician relationships, physician judgment, patient and provider legal safety, and equitable patient care are all directly under threat. The rising hostility and political and legislative intrusion into certain realms of health care results in real fear for the safety of physicians and patients alike.

The health care system needs to be a place of trust, not fear, where the physician–patient relationship is valued and respected and where everyone’s right to bodily autonomy is secured. Many of the changes suggested in the first principle will also help here, including incentivizing care that centers equity.

4. Structures of discrimination should be acknowledged and undone

The policies, practices, and norms that undergird our health care system perpetuate structures of discrimination and result in inequitable care and outcomes. These structures of discrimination manifest in disparities for patients based on race, income, gender, disability, and so on, but they also impact physician well-being. Undoing structures of discrimination requires much more than a quick, transactional fix, but rather intentional policy changes enacted over years or even decades. Thankfully, there are policy changes that are possible—and necessary—right now.

While there has been increased attention paid to some forms of discrimination in our health care system since 2020, with the COVID-19 pandemic widening existing gaps in access and outcomes, the response has not necessarily focused on addressing the root causes. A critical first step toward change is increasing transparency so that the extent of the problem as described above is made more visible to everyone. Transparency alone is insufficient, of course, and needs to be accompanied by a real shift in resources, to move away from supporting the current, discriminatory system and instead invest in people and places that have historically been disinvested in. We also need a real shift in accountability so that all parts of the health care system, including medical schools, are incentivized to advance equity for providers and patients.

Many of the other principles in this section will also help eliminate discrimination such as increasing transparency, fostering and rewarding relational care, moving away from volume-based payment incentives, and changing the health care culture and environment to make it easier for people to ask for supportive accommodations.

5. Physicians should have safety and security

There are policy changes that can be made to help center the well-being of the workforce to support their wellbeing and ability to provide the best patient care possible. Many of the recommendations outlined above to shift to promoting trusted relationships, prioritizing patient outcomes over profits, and making it easier for physicians to organize, will help to change the organizational culture within health care. Other policy changes that can help promote safety and security for physicians include expanding access to mental and physical health care supports and following the recommendations in the Surgeon General’s report, ensuring access to paid family and medical leave that does not add stress on physicians by coming with punitive financial implications, and shifting practice to promote trauma-informed approaches, which includes support and training for all members of the health care workforce, including physicians.

Policies for a healthy health care system

Building upon the framework of guiding principles, below are some specific policy recommendations to be implemented immediately at the federal, state, and nongovernmental levels that can help move toward achieving long-term change. This list is not meant to be exclusive or exhaustive, but rather a showing of how the principles described above can be put into action.

Federal-level policies

Congress can reduce physician burnout through legislation and holding hearings to raise awareness and spur discussion of possible solutions. Specifically, Congress should:

• amend the Medicare hospital conditions of participation to include worker’s rights, such as twelve to eighteen weeks mandatory paid sick and family leave, and family friendly policies such as on-site quality child and elder care for all workers, including physicians; also, amend the conditions of participation to establish a governance structure for supporting health equity and racial, gender, and disability equity;
• ban anti-competitive terms in physician employment contracts, including eliminating noncompete agreements in health care;
• enact the Abortion Justice Act and eliminate bans on gender-affirming care; and
• hold hearings with physicians, payers, patient and consumer groups, and EHR vendors to discuss ways to simplify provider administrative burden.

U.S. Department of Health and Human Services (HHS) has a broad range of actions it could take to reduce physician burnout. In particular, HHS should do the following:

• The department should pursue rulemaking to require reporting that would help shine a light on many of the administrative, coverage, and financial challenges being faced by patients and providers. Section 2715a of the Affordable Care Act gives HHS wide authority to require reporting from insurers about claims-related issues, including any other data as determined necessary by HHS.
• Centers for Medicare and Medicaid Services (CMS) should continue to advance value-based payment models that center health equity and expand the shift away from volume-based payment for physicians, but also explicitly address physician agency, autonomy, judgment, burden, and value of patient and provider time, conversation, and relationship building.
• CMS should expand quality reporting requirements on the part of insurers, hospitals, and clinicians that incentivizes trusted, relational care between patients and providers, such as incorporating the Cycle of Respectful Care as part of accountability frameworks moving forward.
• CMS should require quality measurement reporting for health care systems that includes well-being data reported by physician and stratifies data by race, gender, disability, and other demographic groups.
• CMS should partner with Substance Abuse and Mental Health Services Administration (SAMHSA) to support and implement trauma-informed care approaches in health care systems, including requiring trauma-informed support and training to physicians and all members of the health care workforce.
• Centers for Disease Control and Prevention (CDC) should invest in significant, consistent, tested public health communications messaging and narrative work to improve trust in health care and public health.

The Federal Trade Commission (FTC) has several actions it can take to reduce physician burnout, and specifically should do the following:

• pursue its proposed ban on noncompete agreements and ensure that they apply to all hospitals;
• lower the threshold for merger review so that FTC has oversight over a larger number of mergers, and also require accompanied reporting on equity impacts of proposed merger; and
• in partnership with the Federal Communications Commission (FCC), hold social media companies and organizations accountable for the role they play in the spread of medical misinformation and the consequent mental and physical harm caused to consumers as a result.

The National Labor Relations Board should do the following:

• strengthen worker protections in the health care setting, including protecting physician rights to unionize, expanding whistleblower protections as well as physician and other health care worker safety and equitable accommodations.

State-level policies

There are many actions that states can take to reduce physician burnout. Wherever possible state legislatures, administrations, and agencies should:

• mandate equity-focused health care competition task forces with the authority and accompanying resources to identify ways to expand competition and accountability to advancing health equity in the state;
• expand regulatory oversight of health care markets and anti-competitive practices, including requiring reporting about potential impacts on access to equitable, affordable care for patients that will be considered as part of any proposed merger approval;
• strengthen accountability of nonprofit hospitals as part of their community benefit requirements that accompany their nonprofit status to ensure participation in new financial models that encourage and support upfront community-based investments in advancing equity and allocating funds in line with community priorities; community benefit requirements should also include requirements related to health care worker (including physician) protections;
• protect the right to abortion and gender-affirming care by not only establishing legal protections, but also including as part of merger reviews in the provider market a report on equitable access to care that includes protection of abortion rights and gender-affirming care rights;
• require programming in all public elementary, secondary, and higher education schools to expose diverse groups of students to the potential of a medical career and the associated training requirements, and create equitable supports to meet them; and
• require physician licensing and credentialing agencies to eliminate any punitive language that discourages physicians and other health care workers from seeking mental health or substance use disorder treatment.

Nongovernmental policies

Health care accreditors play a critical role in ensuring that health-care-providing organizations meet regulatory requirements and standards and achieve high levels of performance and patient care. In order to reduce physician burnout, accreditors should do the following:

• expand requirements to include mentorship and diverse leadership training programs in health care settings;
• include robust requirements regarding partnerships with community-based organizations to expand exposure to medical training for different populations as well as opportunities for medical students to learn more about holistic health needs of the population;
• include requirements to expand loan forgiveness programs and ensure diversity, equity, inclusion, access, and belonging in medical training; this might include an examination of honors programs and recognition, not simply siloed equity offices or efforts;
• include anonymous physician surveys as part of accreditation requirements to ascertain wellbeing, equity, inclusion, access, and belonging in health care organizations; and
• require commitment to anti-racist medical practice.

Measurement developers have a role to play in addressing these broader issues because many of the measures that are in use by regulators and accreditors do not approach issues related to burnout. Some of these measurement areas in need of attention include:

• expand the development of measures that assess health care organizational culture, psychological safety, and other issues that relate to physician burnout; and
• ensure that measurement is developed with input from a diverse array of physicians from a variety of backgrounds and specialties, other members of the health care workforce, and patients.

Private foundations have a role to play in increasing awareness of physician burnout and facilitating problem-solving. In particular, foundations should:

• support convening and collaboration across physician groups, consumer and patient groups, health care worker organizations, and others to align in priorities and shift power to counter increased power of consolidated health care systems; and
• fund advocacy and narrative change efforts to clearly communicate how many of the pain points in our health care system are impacting health care workers, including physicians, and patients and what the implications are for health equity.

Conclusion

Improving the well-being of the physician workforce is urgent and critical. Physicians are burning out at faster rates than in previous years, which has implications not only for their health but for equitable health outcomes and access for all of us. Many physicians will leave the profession because of burnout, exacerbating already problematic health care workforce shortages. The pain points in the system are related to economic, political, and discriminatory factors and fixing them won’t be easy or quick. Policy change that upholds principles relating to shifting and aligning financial incentives, protecting and supporting relational care, acknowledging and undoing structures of discrimination, and promoting safety and security are necessary.

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31. The authors of this report are not weighing in on the debate about scope of practice and whether physician’s assistants and advanced practice nurses can and should replace physicians in order to save money without an impact on quality. We are only acknowledging the stress that this adds to physicians’ work lives.
32. Louis Jamtgaard and Lawrence M. Lewis, “The Monetization of Emergency Medicine,” Missouri Medicine, June 2023, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10317107/#b2-ms120_p0172.
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Tags: health care, health care reform, health equity